Quality Homecare Professionals Employment Application Fields marked with an * are required First Name * Middle Name Last Name * Phone * Email * Date of Birth * Address City State - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC ARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EAST ARMED FORCES AMERICA (EXCEPT CANADA) ARMED FORCES PACIFIC Zip / Postal Code Driver's License If applicable Social Security Number How did you hear about us? Type of Employment Desired Full-Time Part-Time PRN Position applied for Specify Days and Hours Available Current hourly pay rate Desired pay per hour Are you legally eligible to work in the US? Yes No Are you available to work Call Outs, if needed? Yes No Have you ever been employed at Quality Homecare Professionals? Yes No If yes, when? Why did you leave? Do you have any friends or family employed at this location? Yes No HTML FYI: Conviction will not be a deciding factor in continuing the pre-screening process or potential employment opportunities Have you been convicted of a crime in the last seven (7) years? Yes No If yes, please explain? During the hiring process, do you agree to provide a criminal background check? Yes No During the hiring process, do you agree to provide a Motor Vehicle Record? (if applicable) Yes No Educational History 1 School Name Field of Study Graduated? Yes No Add Fieldset Documents / Certifications 1 Select RN Certification CNA Certification CPR/First Aid Drivers License TB Screening Other (specify below) Other document not listed above Issue Date Expires License / Certificate Number Add Fieldset Caregivers Only The following questions are for Caregivers applicants only. Skip to Employment Background if this section is not applicable to you. What do you think is the most difficult part of caregiving or customer service work? Ms. Jackson asks you to apply BENGAY muscle rub on her back, what would you do? In what situations do we provide services not listed in the SERVICE PLAN? What is DNR? Why is it important to work within your CNA/PCA scope or job description? Employment History 1 Employer Name Employer Phone Address Job Title Supervisor Name Supervisor Phone Reason for Leaving May we contact to verify? Yes No Start Date End Date Leave blank if still employed with this company Starting Hourly Rate Ending Hourly Rate Responsibilities Add Fieldset HTML References: List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please). References 1 Name Relationship Years Acquainted Phone Number Add Fieldset Certification and Release Certification and ReleaseI certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumers reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I understand that I am not obligated to disclose sealed or expunged records of conviction or arrest. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. EOE We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, national origin, ancestry, veteran status, medical condition, sexual orientation, marital status or any other characteristic protected by applicable state or federal civil rights laws. Certification and EOE Confirmation I agree I decline Confidentiality Agreement Confidentiality Agreement This agreement is made between the party named below (the "Employee") and Quality Homecare Professionals (the "Employer") on the below listed date.The Employee agrees to the terms of this Agreement: As a condition of employment the employer requires that all new employees agree to enter into this Confidentiality Agreement (the Agreement). The Employee acknowledges that employment with Employer is sufficient consideration for the Employee to entering into the Agreement. The Employee acknowledges that, in the course of employment, the Employee will, and may in the future, come into possession of certain confidential information belonging to the Employer including but not limited to trade secrets, data, materials, products, technology, computer programs, specifications, manuals, business plans, software, marketing plans, financial information, and other information disclosed or submitted. This confidential information may be embodied in hand written notes by the Employee, computer disks, tapes, paper, or any other media. The Employee hereby covenants and agrees that she or he will at no time, during or after the term of employment with the Employer, use for his or her own benefit or the benefit of others, or discloses or divulge to others, any such confidential information. Upon termination of employment, the Employee will return, retaining no copies or notes, all documents relating to the Employer's business including, but not limited to, reports, lists, correspondence, information, computer files, computer disks, and all other material and all copies of such material, obtained by the Employee during employment nor will the employee attempt to contact or solicit any patients that the employee may have worked with during employment. The Employee recognizes that the Employer may be irreparably damaged by breach of this Agreement and that the Employer shall be entitled to seek an injunction to prevent such competition or disclosure, and will entitle the Employer to other legal remedies, including attorney's fees and costs. The obligations of Recipient herein shall be effective from the date Owner last discloses any Confidential Information to Recipient pursuant to this Agreement. If any part of this Agreement is adjudged invalid, illegal or unenforceable, the remaining parts shall not be affected and shall remain in full force and effect. This instrument, including any attached exhibits and addenda, constitutes the entire Agreement of the parties. No representation or promises have been made except those that are set out in this Agreement. This Agreement may not be modified except in writing signed by all parties. This agreement shall take effect as a scaled instrument and shall be construed, governed and enforced in accordance with the laws of the State of FL, without regards to its conflicts of law provisionsThe descriptive headings used herein are for convenience of reference only and they are not intended to have any affect whatsoever in determining the rights or obligations under this agreement. Certification and EOE Confirmation Copy I agree I decline Employee Sign off Regarding HIPAA Employee Sign off Regarding HIPAAI have read and understand this policy on protecting Patient Health Information (PHI) and security. l understand that should any situation arise where T breach patient confidentiality I will be disciplined up to and including termination. I hereby agree to maintain patient confidentiality in the strictest maimer possible, sharing or discussing patient infom1ation only with those designated care providers or supervisors who have "a need to know" and arc actively involved in the care of services provided to the patient.I further acknowledge that I have been trained in the provisions and laws related to HIPAA compliance during orientation and those patients must sign written permission to allow their health information (PHI) to be disclosed.I further agree that I will protect PHI while driving in my vehicle servicing patients in their homes and will not allow any PHI to be visible inside my vehicle; I will not bring any PHI related to another patient into the homes/facilities of patients I am servicing. HIPAA Confirmation I agree I decline Incident/Accidents Incident/AccidentsI have been thoroughly informed by Quality Homecare Professionals that I MUST report ALL incidents/accidents and any medical, physical, or mental changes in my patients immediately to the HHA Supervisor and or Scheduling Coordinator. I further understand that in the event that I become injured, even a minor injury, I am required to report that incident to my office as soon as possible after an injury. Incidents Confirmation I agree I decline Our agency is available 24/7 OUR AGENCY IS AVAILABLE BY PHONE 24 HOURS A DAY. THE ANSWERING SERVICE WILL RESPOND AFTER 5PM ON WEEKDAYS AND ON WEEKENDS / HOLIDAYS Acknowledgement and Understanding of Zero Tolerance Sexual Abuse Policy Acknowledgement and Understanding of Zero Tolerance Sexual Abuse Policy I acknowledge that l have received and read the sexual abuse policy and/or have had it explained to me. I understand that the organization will not tolerate any employee, volunteer, board member or third party who commits sexual abuse. Disciplinary actions will be taken against those who are found to have committed sexual abuse.I understand that it is my responsibility to abide by all rules contained in the policy. I also understand how to report incidents of sexual abuse as set forth in the abuse policy, including retaliating against any employee/volunteer exercising his or her rights under the policy. Zero Tolerance Confirmation I agree I decline Type "I am not a robot" below * If you are a human seeing this field, please leave it empty.